stroke core measures 2021

To submit a research proposal for the Get With The Guidelines - Stroke program, email a completed Get With The Guidelines Data Request Form (download) to QualityResearch@heart.org. endobj The AMA is a third party beneficiary to this Agreement. See how our expertise and rigorous standards can help organizations like yours. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. The American Medical Association does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. Core Rulebook (disambiguation) This is a disambiguation page; that is, one that points to other pages that might otherwise have the same name.Pathfinder 2E.Expand your capabilities by selecting general feats that improve your statistics or give you. A hospitals ischemic stroke patient population size is 200 patients during March. The Differences Between The 5 Major Stroke Measure Sets, Thrombolytic Therapy: Inpatient Admission, Antithrombotic Therapy By End of Hospital Day 2, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship), CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only, CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), 1. Set the Initial Patient Population Reject Case Flag to equal No. Sometimes it works best to start small and build on success. Find the exact resources you need to succeed in your accreditation journey. Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. Claims-Based Measures by Category Claims-Based Patient Safety Measures for 2022 Claims-Based Mortality Measures for 2022 Claims-Based Coordination of Care Measures for 2022 CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. An antithrombotic agent is a drug that reduces the formation of blood clots. . The CSTK Initial Patient Population is unique in that it is comprised of three distinct subpopulations: ischemic stroke patients who do not undergo a reperfusion therapy (i.e., procedure), ischemic stroke patients who undergo a reperfusion therapy (IV t-PA, IA t-PA, or mechanical endovascular reperfusion (MER) therapy), and hemorrhagic stroke patients. 1 0 obj A hospitals Hemorrhagic sub-population is 3 patients during January. Data collection for STK-OP-1 will replace ASR-OP-2. The most common signs and symptoms of HF are shortness of breath on exertion; orthopnea; weight gain with edema in the feet, legs, or lower back; fatigue; and weakness. In the specifications manual, Version 2021B, it is in Section 7: Joint Commission National Quality Measures Data Processing, Joint Commission Stroke Measures table: https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html. The CQMC is a diverse coalition of health care leaders representing over 75 consumer groups, medical associations, health insurance providers, purchasers and other quality stakeholders, all working together to develop and recommend core sets of measures by clinical area to assess and improve the quality of health care in America. 1-800-242-8721 <> Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. A hospitals ischemic stroke patient population size is 129 cases during March. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Get With The Guidelines- Stroke supports hospitals in many ways, including: Data submission and feedback reporting are performed using the American Heart Association's Get With The Guidelines Registry (IRP)(link opens in new window). A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. . To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). Remember that changes do not have to be large. CMS is already using measures from the each of the core sets. It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. Part 2: A review of the different stroke certifications. The next measure set we review is abbreviated ASR-IP/OP. Through the use of a multi-stakeholder process, the Collaborative promotes alignment and harmonization of measure use and collection across payers in both the public and private sectors. The AMA does not directly or indirectly practice medicine or dispense medical services. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 20% of this subpopulation or 78 cases for the quarter (20% of 392 equals 78.4 rounded to the next highest whole number equals 78). I hope this high-level overview was helpful and can be a reference for you. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. ASR-IP-3: Discharged on Antithrombotic Therapy4. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. {8Dm.;JHTBXEXh^^^.Y)oH 6K;ANf!;*#.\1\c"1cKE. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 84 cases for the quarter. The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. The following links provide you with information available on past, present and future versions of the specification manuals, including release notes, measure information forms, data dictionaries, missing and invalid data, population and sampling, data transmission, tools and resources, and appendices. Using the monthy sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 14 cases for the month. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. CSTK-05 Hemorrhagic Transformation, 1. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. CPT is a registered trademark of the American Medical Association. STK-8 Stroke Education18. Quarterly sampling for the two combined populations for Joint Commission certification purposes. Test your ideas. Drive performance improvement using our new business intelligence tools. STK-4 Thrombolytic Therapy10. STK-6 Discharged on Statin Medication12. Return to Clinical Data Processing Flow in the Data Processing section. It is important to always refer to the latest edition. This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. stream STK-1 Venous Thromboembolism (VTE Prophylaxis)12. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. %PDF-1.5 One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. The core measurescan be found at: http://www.qualityforum.org/cqmc/. U.S. Government Rights 2 0 obj The required quarterly sample size would be 100% of the patient population or 5 cases for the quarter, No sampling; 100% Initial Patient Population required. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . Using the monthly sampling table for the Ischemic sub-population, the sample size required is 20% of this sub-population, or 46 cases for the quarter (twenty percent of 228 equals 45.6 rounded up to the next whole number equals 46). >0SPJ*@6W/rq+ERY_X&14>k( Using the quarterly sampling table for the Ischemic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. The Core Quality Measure Collaborative, led by the Americas Health Insurance Plans (AHIP) and its member plans Chief Medical Officers, leaders from CMS and the National Quality Forum (NQF), as well as national physician organizations, employers and consumers, worked hard to reach consensus on core performance measures. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 20% of this subpopulation or 45 cases for the quarter (20% of 223 equals 44.6 rounded to the next highest whole number equals 45). This is a big year for Quality. The six measures are: . This content does not have an English version. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. The change in the performance measure requirements for Acute Stroke Ready Hospitals, (i.e., STK-OP-1 replacing ASR-OP-2 effective with discharges on and after July 1, 2021) can be found in several places. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. The required monthly sample is 60 cases. https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html, The Joint Commission (ASR-IP, ASR-OP, PSC, TSC, CSC), program comparison sheet with guidelines of certification requirements, Centers for Medicare & Medicaid Services (CMS), The Joint Commission Stroke Certification Programs Program Concept Comparison, Specifications Manual for Joint Commission National Quality Measures (version 2021B), Acute Stroke Ready Hospital Certification (ASRH), Standardized Performance Measures for Acute Stroke Ready Hospitals, Primary Stroke Center Certification (PSC), Standardized Performance Measures for Primary Stroke Centers, Comprehensive Stroke Center Certification (CSC), Standardized Performance Measures for Comprehensive Stroke Centers, Standardized Performance Measures for Thrombectomy-Capable Stroke Centers, Using the New Opioid eCQM to Improve Prescribing Practices and Patient Care, 2021 Quality Reporting Deadlines Calendar, 2023 Promoting Interoperability Requirements, A Guide to The Joint Commissions New Health Equity Requirements, Hospital eCQM Results Are In: A Review of the January 2023 Care Compare Refresh, [Download] 2021 Hospital IQR Program Requirements, [Download] Hybrid Measure Implementation Guide, Hemorrhagic Transformation (Overall Rate), Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival, Ischemic Stroke with Procedure (Thrombolytic Therapy or Mechanical endovascular therapy). We can make a difference on your journey to provide consistently excellent care for each and every patient. STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% of the Initial Patient Population is required, Patient level data must be processed in order to submit your aggregate data. You, your employees and agents are authorized to use CPT only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. For the purposes of this blog, since we are focusing specifically on stroke measures, there is only one stroke measure that is used for Accreditation purposes by both CMS and TJC: OP-23. There are five major stroke measure sets. We help you select and set up measures that make sense based on your hospitals situation. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 20% of this subpopulation or 26 cases for the month (20% of 129 equals 25.8 rounded to the next highest whole number equals 26). Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. To develop the core measure sets the Collaborative split into workgroups and reviewed measures currently in use by CMS and health plans as well as measures endorsed by NQF for the individual measure sets. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. decreased providers collection burden and cost. . Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. <> An injection of TPA is usually given through a vein in the arm within the first three hours. Medisolv Can HelpThis is a big year for Quality. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. STK-10 Assessed for Rehabilitation, Measures for TJC Comprehensive Stroke Center Certification, 1. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the (AMA is not recommending their use. endobj The Centers for Medicare & Medicaid Services (CMS) has posted the electronic clinical quality measure ( eCQM) specifications for the 2021 reporting period for Eligible Hospitals and Critical Access Hospitals, and the 2021 performance period for Eligible Professionals and Eligible Clinicians. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. 7272 Greenville Ave. Patients admitted to the hospital for inpatient acute care are included in the CSTK 1-Ischemic Stroke Without Procedure subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. This began in Fiscal Year (FY) 2014. They also could require other measures. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. CSTK-09 Arrival Time to Skin Puncture, 8. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. A hospitals Ischemic sub-population is 100 during the first quarter. 10960 Grantchester Way, Suite 520Columbia, MD 21044. Here is a diagram that outlines the submission differences. <> 3= recommended; the outcome measure has good psychometric . This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> 690 0 obj <>stream The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). A hospital may choose to use a larger sample size than is required. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. This is increasingly important as the health care system moves towards value-based reimbursement models. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. STK-2 Discharged on Antithrombotic Therapy8. Once a patient is qualified, he/she moves to the second part of the algorithm which tells you which sub-population he/she falls into. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. Please see link below for more information. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. This content does not have an Arabic version. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. The ACM is a pass-fail measure at the individual patient level that asks whether an eligible patient has received all of the appropriate care for the condition for which he or she is being treated. Especially if you use an EHR vendor right now, youll notice a huge difference. Share sensitive information only on official, secure websites. x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. STK-6 Discharged on Statin Medication17. Secure .gov websites use HTTPSA Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. May 2021 Measure ID# Measure Short Name Measure Description STK-1 Venous Thromboembolism (VTE) This measure captures the proportion of ischemic or hemorrhagic Prophylaxis stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. STK-6 Discharged on Statin Medication9. sI % Dallas, TX 75231, Customer Service Measure Type: InpatientNumber of Measures Included: 3 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Measure Type: OutpatientNumber of Measures Included: 2 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Door to Transfer to Another Hospital**RETIRED Effective July 1, 2021**, Note: All Joint Commission certified acute stroke ready hospitals, as well as those seeking initial certification, will be required to collect the STK-OP-1 Door to Transfer to Another Hospital measure for discharges on and after July 1, 2021. They are responsible for making the necessary updates to the measure and for informing NQF (National Quality Forum) about any changes that are made to the measure on an annual basis. Create your baseline by entering 30 records into the Patient Management Tool. Download Get With The Guidelines- Stroke fact sheets and forms here. The American Medical Association reserves all rights to approve any license with any Federal agency. TARGET: STROKE MEASURE A hospitals ischemic stroke patient population size is 392 cases during the second quarter. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. STK-OP-1 Door to Transfer to Another Hospital, 1. ruTv?U J4lUBex(a8{g$CHj ~>-z I&8:+hlvM(XdvY;D|BOl,Yu'D> YR9Gbl6GrJ8'},^V)\i/0 Gg:} >!81I88{'swe )I6v#{$&YymLyn\tl S3r6.o?x@q$_1A=U$H3%QUx . CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. STK-10 Assessed for Rehabilitation. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. *** AHRQ is the measure steward for the survey instrument in the Adult Core Set (NQF #0006) and NCQA is the developer of the survey administration protocol. CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. Ongoing monitoring by the Collaborative of the use of these measures will enable modifications of measure sets, as needed and based on lessons learned, including minimizing unintended consequences and selection of new measures as better measures become available. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. We keep you on track for your submission deadlines and ensure you dont miss critical dates. Program details are found in Part 2. Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements %PDF-1.7 Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. A hospitals Hemorrhagic sub-population is 100 during the first quarter. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Today, the Core Quality Measures Collaborative (CQMC) released four updated core measure sets covering specific clinical areas as part of its mission to provide useful quality metrics as the nation's health care system moves from one that pays based on volume of services to one that pays for value. An official website of the United States government Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 11 cases are sampled. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Using the monthly sampling table for the Ischemic sub-population, the sample size is less than the minimum required monthly sample size, so 100% of this sub-population is sampled. CSTK-06 Nimodipine Treatment Administered6. ASR-OP-2c Ischemic Stroke; drip and ship4. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. A hospitals hemorrhagic stroke patient population size is 295 cases during March. This section includes the measure type (inpatient vs outpatient), the number of measures in the set, which certification the measure set is a part of, a list of the measures in the set and the associated algorithm. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. See our editorial policies and staff. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. Stroke Core Stroke Measures As a Certified Stroke Center the stroke committee would like to provide physicians with updates on how we are performing on the stroke performance and quality measures. %%EOF There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. ASR-OP-2b Hemorrhagic Stroke3. If the ICD-10-CM Principal Diagnosis Code is on Table 8.1, the patient is in the first Ischemic Stroke sub-population and is eligible to be sampled for the first STK sub-population. The American Medical Association does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. By not making a selection you will be agreeing to the use of our cookies. If the Patient Age is less than 18 years, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. %PDF-1.5 National Center Each measure includes patients from one or more categories.